Provider Demographics
NPI:1467441618
Name:GORDON, MARK WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2301 N UNIVERSITY DR
Mailing Address - Street 2:#203
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-3617
Mailing Address - Country:US
Mailing Address - Phone:954-964-1490
Mailing Address - Fax:954-963-3453
Practice Address - Street 1:7100 W 20TH AVE
Practice Address - Street 2:#703
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-1897
Practice Address - Country:US
Practice Address - Phone:305-822-4515
Practice Address - Fax:954-963-3453
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2020-03-03
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Provider Licenses
StateLicense IDTaxonomies
FLME13633208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL056068500Medicaid
FL92213Medicare ID - Type Unspecified
FLD59990Medicare UPIN